Ds 2019 Form - Application For A Certificate Of Eligibility Page 2
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3II – DEPENDENTS’ INFORMATION (if applicable)
Total Number of Dependents: ________________
For each dependent (spouse and unmarried children under the age of 21) requesting a dependent visa in order to accompany the
student to the U.S., provide the following information. If more than two dependents will accompany the applicant, copy this
page and attach. Also, refer to Declaration and Certification of Finances Form for the expenses for each additional dependent.
17. Dependent
a. Dependent Family/Last Name___________________________________ b. First/Given Name ________________________________
Print as in passport
Print as in passport
c. Date of Birth ___________________________ d. Place of Birth ________________________________________________________
mm/dd/yyyy
City
Country
e. Country (ies) of Citizenship _____________________________________ f. Relationship to student ___________________________
h. If dependent is currently in the U.S., please list his/her immigration status _________________________________________________
18. Dependent
a. Dependent Family/Last Name___________________________________ b. First/Given Name ________________________________
Print as in passport
Print as in passport
c. Date of Birth ___________________________ d. Place of Birth ________________________________________________________
mm/dd/yyyy
City
Country
e. Country (ies) of Citizenship _____________________________________ f. Relationship to student ___________________________
h. If dependent is currently in the U.S., please list his/her immigration status _________________________________________________
III – IMMIGRATION STATUS INFORMATION
19. Are you currently in the U.S. -OR- Are you currently or have you been recently enrolled in a U.S. educational institution under
an F-1 /J-1 student visa classification?
□
□
Yes -- Complete items 20-28 below
No -- Please proceed to Section IV.
20. What is your current immigration status?
F-1_______
J-1 _______
Other, please specify _______
21. Are you requesting a change of your current visa classification to a student visa status (staying in the U.S.)? Yes______
No______
22. Are you requesting a transfer to Northeastern? (ISSI Form 121 is required-see below)
23. Which institution issued your last form I-20 or DS-2019?______________________________ SEVIS # ____________________
24. If you now have or have had in the past an Employment Authorization Card (EAD card), please list the card expiration date ____________
mm/dd/yyyy
: Students currently or recently enrolled in a U.S. educational institution under an F-1 or J-1 visa classification who plan to
NOTE
attend Northeastern are required to complete the Transfer-In Notification Form: ISSI Form 658 available from the Northeastern
University School of Professional and Continuing Studies applying or online at Federal regulations
do not permit Northeastern to process SEVIS transfer until the student’s current school completes the Transfer-In Notification
Form: ISSI Form 658.
25. If you are currently in the U.S. in J-1 status, please check one of the following categories:
□
□
□
Student
Scholar
Other, please specify__________________________________________________
26. Are you subject to the two-year home-country physical presence requirement?
Yes ______
No_____
Received a waiver_____
27. List the DS-2019 sponsor’s name and complete address ____________________________________________________________
____________________________________________________________________________________________________
28. Have you filed a petition or has a petition been filed on your behalf to adjust your status to U.S. Permanent Resident?
□
□
Yes
No
▼ IMPORTANT ▼
An I-20 or DS-2019 will not be processed or issued without the copies of the required supporting documents listed in Section V.
ISSI 657-LAL-[Q] 71006
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